Commonly when clients present to my office, they are already taking one or more medications for mental health. We call those medications “psychotropic medications.” One of the most common frustrations I hear is with the “trial and error” process of prescribing. Unfortunately, there’s no way to know ahead of time how well or even if any particular drug will “work” for a person, so prescribers do their best to choose based on research, clinical experience, and a person’s mental health and medical history. On top of the trial and error process is the delay it takes for many of the medications to build up in your body to a therapeutic dose — 4 to 6 weeks for many medications. This means it can take quite a while to find the “right” medication or the right combination of medications to optimally manage symptoms. Along the way, people are dealing with side effects in addition to the debilitating symptoms that led them to a psychiatrist’s office in the first place. Despite those frustrations, psychotropic medications can be very useful for managing symptoms, and actually research for some mental health conditions indicates the combination of medication and psychotherapy is the best approach. But psychotropic medications are complicated and somewhat enigmatic, so I’m beginning this series to try to bring you the basics of medications. Now, remember I’m not a physician of any sort, so I can’t prescribe medications and I don’t claim to be an expert on psychopharmacology or psychotropic medications. But these are the basics, and hopefully it will give you enough background information that you feel more confident asking your prescriber informed questions about medication. Let’s start with the antidepressants.
“Despite those frustrations, psychotropic medications can be very useful for managing symptoms, and actually research for some mental health conditions indicates the combination of medication and psychotherapy is the best approach.”
Neuroscience Basics
First we need to get down with some basics of neuroscience. The cells in our brain are called neurons, and they communicate with each other by sending messages from neuron to neuron via certain chemicals. There are several of these different chemical messengers in the brain, some of which you’ve probably heard of, like dopamine and serotonin. Changing the amount of these chemicals in the brain changes how effectively messages can travel, which changes all sorts of things, including how you think and feel and act. That’s part of how we think certain mental health conditions work – there’s a depletion (or excess) of certain chemicals that changes how messages are communicated across the brain. Reverse that process (e.g., with medication), and conditions could improve.
Tricyclic Antidepressants
The first antidepressant medications were developed in the 1950s — iproniazid (an MAOI, more on that later), which until then had been used to treat tuberculosis, and imipramine, which was the first drug in the tricyclic antidepressant class. More tricyclic antidepressants were developed in the 1960s, and they work by increasing the amount of serotonin and norepinephrine in the brain. Medications in this class include
- Imipramine (Tofranil)
- Amitriptyline (Elavil)
- Nortriptyline (Pamelor)
- Doxepin (Silenor, Zonalon, Prudoxin)
- Trazodone
- Amoxapine (Asendin)
- Protriptyline (Vivactyl)
- Maprotiline (Ludiomil)
- Desipramine (Norpramin)
They work pretty well for decreasing the symptoms of depression, but they have some pretty nasty side effects for some people, including
- Blurred vision
- Dizziness
- Daytime drowsiness
- Increased heart rate
“That’s part of how we think certain mental health conditions work – there’s a depletion (or excess) of certain chemicals that changes how messages are communicated across the brain. Reverse that process (e.g., with medication), and conditions could improve.”
MAOIs
With the side effects of tricyclics being intolerable for most people, a new class of antidepressants was developed, called MAOIs. MAOI stands for monoamine oxidase inhibitor, which essentially describes how the medications work. Examples of medications in this class are
- Phenelzine (Nardil)
- Tranylcypromine (Parnate)
- Isocarboxazid (Marplan)
SSRIs
The SSRIs began to be developed and marketed in the late 1980s and 1990s. SSRI stands for selective serotonin reuptake inhibitor, which describes essentially how the medications work (they inhibit “reuptake” of serotonin, which by a complicated process basically means you have more serotonin floating around in your brain). Medications in this class include
- Fluoxetine (Prozac)
- Sertraline (Zoloft)
- Fluvoxamine (Luvox)
- Paroxetine (Paxil)
- Citalopram (Celexa)
- Escitalopram (Lexapro)
- Vilazodone (Viibryd)
- Vortioxetine (Trintellix)
- Sexual dysfunction
- Headaches
- Nausea
- Nervousness
- Insomnia
- Agitation
But these side effects often decrease once you have been taking the medication for a while.
SNRIs
In the late 1990s, a related but new class of medications was developed, called the SNRIs. SNRI stands for serotonin and norepinephrine reuptake inhibitors. Just like the original tricyclic antidepressants, these medications increase the amount of serotonin and norepinephrine in the brain, but their side effect profile is way better. They’re not only really good for managing symptoms of depression, but they’re also commonly prescribed for anxiety disorders, Panic Disorder, and other mood disorders. Medications in this class include
- Venlafaxine (Effexor)
- Desvenlafaxine (Pristiq)
- Duloxetine (Cymbalta)
- Levomilnacipran (Fetzima)
- Nefazodone (Serzone)
- Levomilnacipran (Fetzima)
- Mirtazapine (Remeron)
- Dry mouth
- Constipation
- Bladder problems
- Sexual dysfunction
Now if you’re comparing all this to your own medication list, you might have noticed bupropion (Wellbutrin) hasn’t been mentioned. Wellbutrin is an interesting drug because it doesn’t “fit” in any of the other classes, and it’s chemically unrelated to these other drugs. You might have noticed as you looked through the list of drugs in each class that they have similar-sounding names (e.g., the tricyclics commonly end with “mine” or “line”). This usually means the drugs are chemically very similar, which explains why they have similar effects. The nuances in the chemical structure explains why one drug in a class might not be a great fit for you, while another works wonderfully. Anyways, Wellbutrin is in a class of its own and is a norepinephrine and dopamine reuptake inhibitor. When combined with an SSRI or SNRI, you’re working on three different neurotransmitters – serotonin, norepinephrine, and dopamine.
“The nuances in the chemical structure explains why one drug in a class might not be a great fit for you, while another works wonderfully.”
Warnings
You’ve noticed many of the antidepressants work by increasing the amount of serotonin you have in your brain. This is usually a good thing for relieving the symptoms of depression, but combining an SSRI with another medication that affects serotonin can lead to the development of serotonin syndrome. Serotonin syndrome can be quite dangerous, with symptoms including fever, confusion, muscle rigidity, and heart/liver/kidney problems. So, never take an additional medication with an antidepressant without talking to your physician first.
If you take an antidepressant, you might have noticed there is a warning on the bottle against drinking alcohol while taking the medication. Alcohol can reduce the effectiveness of the medication AND antidepressant medications can increase the effects of alcohol, so combining alcohol with antidepressants can be problematic in both directions.
One more warning. You’ve also heard a lot about the increased risk for suicide in children and adolescents who take antidepressant medications. Research indicates antidepressant medication use in individuals under age 24 is associated with an increased risk of suicidal ideation or a suicide attempt. Although the research has been primarily with SSRIs, this warning applies to all antidepressant medications.
Comprehensive Treatment
Before I leave, just one more thing. Antidepressants can be a godsend for many people struggling with depression. But often, they’re only part of a treatment plan for depression. So make sure you consider how evidence-based psychotherapy (like cognitive-behavioral therapy or interpersonal psychotherapy) could enhance your recovery.
Upcoming posts in this series
Hey, make sure you subscribe so you don’t miss out on these upcoming posts:
- Anxiety Medications
- Mood Stabilizers
- Antipsychotics (check out this one — they’re used commonly these days for all kinds of mental health conditions, not just psychotic disorders)
Source: Patzer, D. Overview of Psychopharmacology. Magellan Health.
Source: Scheifler, P. Bipolar and Related Disorders. Magellan Health
Hayden C. Finch, PhD,
is a practicing psychologist
in Des Moines, Iowa.
